Fetomaternal hemorrhage in threatened abortion

Prevention of RhD alloimmunization in the first trimester of pregnancy: Clinical practice guidelines of the French College of Obstetricians and Gynecologists

The French College of Obstetricians and Gynecologists has decided to update its clinical practices guidelines for preventing RhD alloimmunization in the first trimester of pregnancy. The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the Patients, Intervention, Comparison, Outcome (PICO) format and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed using Pubmed, Cochrane, EMBASE, and Google Scholar databases. The quality of evidence was assessed (high, moderate, low, very low) and a recommendation was formulated: strong, weak, or no recommendation. The recommendations were reviewed in two rounds by members of the scientific board of the French College of Obstetricians and Gynecologists (Delphi survey) in order to select the consensus recommendations. The three recommendations from the PICO questions were agreed upon through the use of the Delphi method. It is not recommended to administer RhD immune globulin before 12 weeks of gestation to reduce the risk of alloimmunization in the event of induced or spontaneous abortion in RhD-negative patients when the progenitor is RhD-positive or unknown (weak recommendation, very low-quality evidence). It is not recommended to administer RhD immune globulin before 12 weeks of gestation to reduce the risk of alloimmunization in the event of bleeding (weak recommendation, very low-quality evidence). The quality and quantity of literature data are insufficient to determine whether injection of RhD immune globulin can reduce the risk of alloimmunization in ectopic pregnancy, so no recommendation could be made.

[Prevention of Rh D alloimmunization in the first trimester of the pregnancy: French College of Obstetricians and Gynecologists guidelines for clinical practice]

OBJECTIVE

To provide recommendations for the prevention of Rh D alloimmunization in the first trimester of pregnancy.

MATERIALS AND METHODS

The quality of evidence of the literature was assessed following the GRADE methodology with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on Pubmed, Cochrane, EMBASE, and Google Scholar databases. The quality of evidence was assessed (high, moderate, low, very low) and a recommendation was formulated: (i) strong, (ii) weak, or (iii) no recommendation. The recommendations were reviewed in two rounds with reviewers from the scientific board of the French College of the OB/GYN (Delphi survey) to select the consensus recommendations.

RESULTS

The three recommendations from PICO questions reached agreement using the Delphi method. It is recommended not to administer Rh D immunoglobulin before 12 weeks of gestation to reduce the risk of alloimmunization in case of abortion or miscarriage, in RhD negative patients when the genitor is RhD positive or unknown (Weak recommendation. Very low-quality evidence). It is recommended not to administer Rh D immunoglobulin before 12 weeks of gestation to reduce the risk of alloimmunization in cases of bleeding in an ongoing intrauterine pregnancy (Weak recommendation. Very low-quality evidence). The literature data are insufficient in quality and quantity to determine if the injection of Rh D immunoglobulin reduces the risk of alloimmunization in the case of an ectopic pregnancy (No recommendation. Very low-quality evidence).

CONCLUSION

Even though the quality of evidence from the studies is very low, it is recommended not to administer Rh D immunoglobulin in case of abortion, miscarriage or bleeding before 12 weeks of amenorrhea. The quality of evidence was too low to issue a recommendation regarding ectopic pregnancy.

Fetal-Maternal Hemorrhage in First-Trimester Intrauterine Hematoma

OBJECTIVE

The objective of this study was to compare the frequency and percentage of fetal hemoglobin (HbF%) by flow cytometry of (1) first-trimester asymptomatic patients with intrauterine hematoma (IUH), (2) first-trimester pregnant patients with vaginal bleeding (VB), and (3) first-trimester asymptomatic pregnant women without hematoma.

METHODS

Prospective study involving pregnant women in the first trimester of pregnancy. Patients with ultrasound findings of asymptomatic hematoma and with VB were paired with asymptomatic pregnant women of same gestational age without hematoma (control group [CG]). Maternal blood HbF% was evaluated by flow cytometry. The groups were compared in terms of circulating fetal hemoglobin and HbF%.

RESULTS

Sixty-six patients were selected, 22 with hematoma, 17 with bleeding, and 27 in the CG. Fetal hemoglobin was detected in 15 patients with hematoma (68.2%) and 13 with bleeding (76.5%) and in 20 of the control (74.1%) (p = 0.830). The mean HbF% of each group was 0.054, 0.012, and 0.042 for hematoma, bleeding, and control, respectively, and differences were not significant (p = 0.141). There was a moderate negative correlation between the volume of hematoma and HbF% (rSpearman = -0.527; p = 0.012).

CONCLUSIONS

The fetal-maternal hemorrhage expressed by Hbf% in first-trimester pregnancies did not seem to differ between patients with and without ultrasound findings of IUH.

Practice Modification for Pandemics: A Model for Surge Planning in Obstetrics

This review highlights proposed pandemic-adjusted modifications in obstetric care, with discussion of risks and benefits based on available evidence. We suggest best practices for balancing community-mitigation efforts with appropriate care of obstetric patients.

"Provoked" feto-maternal hemorrhage may represent insensible cell exchange in pregnancies from 6 to 22 weeks gestational age

OBJECTIVE

To quantify spontaneous and provoked fetal to maternal cell exchange in the first half of pregnancy. Transfer of fetal red blood cells (FRBCs) into the maternal circulation during the first half of pregnancy is poorly characterized but of clinical relevance for miscarriage management and invasive procedures.

STUDY DESIGN

Prospective, descriptive cohort study of women presenting for surgical termination of pregnancy with sonographically confirmed gestational age (GA). Pre-procedural and post-procedural blood samples were collected to characterize both spontaneous (pre) and provoked (post) cell exchange with analysis via flow cytometry to quantify FRBC count.

RESULTS

A total of 100 patients at 6-22 weeks GA contributed 200 matched pre- and post-procedural samples. FRBCs were identified in 69 patients including 4 who exhibited FRBCs pre-procedure only and 9 post-procedure only, for a total of 65 patients having post-procedural FRBCs. Of patients with FRBCs following their procedure, the majority (n=56, 86%) also exhibited evidence of cells before the procedure with just 9 patients (14%) exhibiting FRBCs only after. No dose-response relationship was appreciable between GA and FRBC count.

CONCLUSION

After experiencing disruption of the placenta with instrumentation, roughly two thirds of patients had detectable FRBCs in maternal circulation following their procedure but-among those that did-the majority also exhibited cell presence prior to the procedure. This leads to further questions regarding the relationship between risk events and alloimmunization potential in previable pregnancies as the rate of spontaneous transplacental cell exchange may be underappreciated and the magnitude of provoked transfer may be overestimated.

IMPLICATIONS

The relationship between feto-maternal hemorrhage risk events and alloimmunization potential in previable pregnancies has previously been poorly characterized but these data reveal spontaneous transplacental cell exchange may be underappreciated and the magnitude of provoked transfer may be overestimated.

Assessment of feto-maternal hemorrhage among rhesus D negative pregnant mothers using the kleihauer-betke test (KBT) and flow cytometry (FCM) in Addis Ababa, Ethiopia

BACKGROUND

This study aimed to assess fetomaternal hemorrhage (FMH) among RhD negative pregnant mothers using two techniques, Kleihauer-Betke (KBT) and Flow cytometry (FCM). To determine if patient-specific doses of prophylactic anti-D warrant further investigation in Ethiopia and wider Africa.

METHODS

Hospital- based cross-sectional study was conducted among 75 RhD negative pregnant mothers using convenient sampling technique.

RESULT

FMH has been detected in 52% and 60% by KBT and FCM techniques, respectively. The volume of FMH quantified in the majority of the cases (92.5% and 87%) was <10 mL fetal blood while >30 mL in 1.3% (1/75) and 2.7% (2/75) as calculated by KBT and FCM, respectively. The FMH calculated by the two methods have good correlation; r = 0.828 (p = 0.000) for categorized and r = 0.897 (p = 0.000) for continuous values and the agreement between the FCM and KBT was moderate with kappa (κ) value of 0.53 (p = 0.000).

CONCLUSION

Most of FMH calculated (<10 mL) could have been neutralized by lower doses which might have lower costs than administering 300 μg dose which is currently in practice in our country for affording mothers. Besides, it also showed that the volume of FMH was >30 mL in 1.3% and 2.7% of the cases as calculated by KBT and FCM, respectively, which need more than 300 μg dose RhIG for neutralization. Further investigation into the cost- effectiveness and scalability of patient- specific dosing of prophylactic anti-D appears warranted.

Significance of the volume of fetomaternal hemorrhage after performing prenatal invasive tests

BACKGROUND

Fetal erythrocytes cross the placenta during gestation, but invasive prenatal procedures might develop into fetomaternal hemorrhage (FMH). We examine whether flow cytometry immunophenotyping might be useful for measuring the volume of FMH after such procedures.

METHODS

Fetal erythrocytes (%) were determined in 153 pregnant women after amniocentesis (129) and chorionic villous sampling (24) using a monoclonal antibody against fetal hemoglobin. Fetal erythrocytes were identified for their high expression of fetal hemoglobin (HbF(++) ). Blood samples from two control groups, 53 healthy males and 21 pregnant women not submitted to invasive tests, were used to establish normal values of circulating HbF(++) erythrocytes in adults.

RESULTS

The highest percentage of HbF(++) erythrocytes in the control groups was 0.015%. The rate of HbF(++) erythrocytes in samples after invasive tests ranged between <0.01% and 0.15%. Seventy-three women (47%) had ≤0.015% HbF(++) erythrocytes, and this rate was higher in 80. Nine women presented >1 ml of FMH (volume of packed cells corresponding to 0.054-0.15% HbF(++) erythrocytes), but only two had sonographic evidence of bleeding.

CONCLUSIONS

Most women in our series had a very low volume of FMH after the invasive tests. Acute bleeding should be thoroughly investigated in women with either more than 1 ml of packed cells or more than 0.05% of HbF(++) erythrocytes. Intermediate values between >0.015% and <0.05%, should be carefully considered depending on the week of gestation. Data obtained before 15 weeks might reflect previous cell trafficking between fetus and mother instead of acute hemorrhage.

Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin?

OBJECTIVE

To examine whether literature supports the use of Rh immune globulin in Rh-negative women with first trimester spontaneous abortions to prevent maternal sensitization to the fetal Rh antigen and subsequent fetal morbidity and mortality.

METHODS

We searched MEDLINE (1966-2005), the Cochrane Central Register of Controlled Trials, EMBASE (1990 to 2005), and the reference sections of the articles found. The search is considered updated to December of 2005. Search terms included vaginal bleeding, Rh negative, Rh immune globulin, RhoGAM, isoimmunization, sensitization, first trimester pregnancy, threatened, and spontaneous abortion.

RESULTS

The evidence to support the use of Rh immune globulin for a diagnosis of first trimester spontaneous abortion is minimal. There is a paucity of well-designed research that examines maternal sensitization or hemolytic disease of the newborn as an outcome in patients receiving, versus not receiving, Rh immune globulin in first trimester bleeding. There is significant evidence to demonstrate fetomaternal hemorrhage in first trimester spontaneous abortions; yet, no studies demonstrate subsequent maternal sensitization or development hemolytic disease in the fetus as a result of this hemorrhage.

CONCLUSION

In summary, there is minimal evidence that administering Rh immune globulin for first trimester vaginal bleeding prevents maternal sensitization or development of hemolytic disease of the newborn. The practice of administering Rh immune globulin to Rh-negative women with a first trimester spontaneous abortion is based on expert opinion and extrapolation from experience with fetomaternal hemorrhage in late pregnancy. Its use for first trimester bleeding is not evidence-based.

Prevention and management of RhD isoimmunization

An Rh-negative woman is at risk for developing Rh isoimmunization upon exposure to RhD antigens from her Rh-positive baby through fetal-maternal hemorrhage. The incidence of Rh isoimmunization and fetal hemolytic disease has decreased substantially since Rh immune globulin was introduced in 1968. When RhD sensitization does occur, careful follow-up of these mothers and judicious intervention can result in good outcomes for most pregnancies. Both Doppler assessment of middle cerebral artery peak systolic velocity and spectral analysis of amniotic fluid at 450 nm (DeltaOD 450) are useful in the diagnosis and management of fetal anemia.

Cell-free fetal DNA levels in maternal plasma after elective first-trimester termination of pregnancy

OBJECTIVE

To determine if first-trimester elective termination of pregnancy affects cell-free fetal DNA (fDNA) levels in maternal plasma.

DESIGN

Prospective cohort study.

SETTING

Clinical and academic research centers.

PATIENT(S)

One hundred thirty-four women who underwent first-trimester elective termination procedures.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Real-time polymerase chain reaction (PCR) amplification and measurement of DYS1, a Y-chromosome sequence, was used as a marker of fDNA.

RESULT(S)

We detected fDNA in pretermination samples from 27 out of 71 patients in the surgical arm, and 29 out of 63 patients in the medical arm. Based on confirmation of male gender in placental tissue, the sensitivity of fDNA detection is 92.6%. We detected fDNA as early as 32 days of gestation, which increased 4.2 genome equivalents/mL/week. In the surgical arm, the mean level of posttermination fDNA, adjusted for the clearance of fDNA in maternal blood, was higher than projected based on an expected increase with gestational age. In the medical arm, six patients had increased fDNA levels up to 11 days following termination.

CONCLUSION(S)

We found that fDNA can be reliably quantified in the early first trimester; fDNA elevation that occurs shortly after surgical termination may reflect fetomaternal hemorrhage or destruction of trophoblastic villi. Continued elevation of fDNA for several days may occur following medical termination.

Prevention of Rh alloimmunization

OBJECTIVE

To provide guidelines on use of anti-D prophylaxis to optimize prevention of rhesus (Rh) alloimmunization in Canadian women.

OUTCOMES

Decreased incidence of Rh alloimmunization and minimized practice variation with regards to immunoprophylaxis strategies.

EVIDENCE

The Cochrane Library and MEDLINE were searched for English-language articles from 1968 to 2001, relating to the prevention of Rh alloimmunization. Search terms included: Rho(D) immune globulin, Rh iso- or allo-immunization, anti-D, anti-Rh, WinRho, Rhogam, and pregnancy. Additional publications were identified from the bibliographies of these articles. All study types were reviewed. Randomized controlled trials were considered evidence of highest quality, followed by cohort studies. Key individual studies on which the principal recommendations are based are referenced. Supporting data for each recommendation is briefly summarized with evaluative comments and referenced.

VALUES

The evidence collected was reviewed by the Maternal-Fetal Medicine and Genetics Committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and quantified using the Evaluation of Evidence guidelines developed by the Canadian Task Force on the Periodic Health Exam.

RECOMMENDATIONS

1. Anti-D Ig 300 microg IM or IV should be given within 72 hours of delivery to a postpartum nonsensitized Rh-negative woman delivering an Rh-positive infant. Additional anti-D Ig may be required for fetomaternal hemorrhage (FMH) greater than 15 mL of fetal red blood cells (about 30 mL of fetal blood). Alternatively, anti-D Ig 120 microg IM or IV may be given within 72 hours of delivery, with testing and additional anti-D Ig given for FMH over 6 mL of fetal red blood cells (12 mL fetal blood). (I-A) 2. If anti-D is not given within 72 hours of delivery or other potentially sensitizing event, anti-D should be given as soon as the need is recognized, for up to 28 days after delivery or other potentially sensitizing event. (III-B) 3. There is poor evidence regarding inclusion or exclusion of routine testing for postpartum FMH, as the cost-benefit of such testing in Rh mothers at risk has not been determined. (III-C) 4. Anti-D Ig 300 microg should be given routinely to all Rh-negative nonsensitized women at 28 weeks' gestation when fetal blood type is unknown or known to be Rh-positive. Alternatively, 2 doses of 100-120 microg may be given (120 microg being the lowest currently available dose in Canada): one at 28 weeks and one at 34 weeks. (I-A) 5. All pregnant women (D-negative or D-positive) should be typed and screened for alloantibodies with an indirect antiglobulin test at the first prenatal visit and again at 28 weeks. (III-C) 6. When paternity is certain, Rh testing of the baby's father may be offered to all Rh-negative pregnant women to eliminate unnecessary blood product administration. (III-C) 7. A woman with "weak D" (also known as Du-positive) should not receive anti-D. (III-D) 8. A repeat antepartum dose of Rh immune globulin is generally not required at 40 weeks, provided that the antepartum injection was given no earlier than 28 weeks' gestation. (III-C) 9. After miscarriage or threatened abortion or induced abortion during the first 12 weeks of gestation, nonsensitized D-negative women should be given a minimum anti-D of 120 microg. After 12 weeks' gestation, they should be given 300 microg. (II-3B) 10. At abortion, blood type and antibody screen should be done unless results of blood type and antibody screen during the pregnancy are available, in which case antibody screening need not be repeated. (III-B) 11. Anti-D should be given to nonsensitized D-negative women following ectopic pregnancy. A minimum of 120 microg should be given before 12 weeks' gestation and 300 microg after 12 weeks' gestation. (III-B) 12. Anti-D should be given to nonsensitized D-negative women following molar pregnancy because of the possibility of partial mole. Anti-D may be withheld if the diagnosis of complete mole is certain. (III-B) 13. At amniocentesis, anti-D 300 microg should be given to nonsensitized D-negativeesis, anti-D 300 microg should be given to nonsensitized D-negative women. (II-3B) 14. Anti-D should be given to nonsensitized D-negative women following chorionic villous sampling, at a minimum dose of 120 microg during the first 12 weeks' gestation, and at a dose of 300 microg after 12 weeks' gestation. (II-B) 15. Following cordocentesis, anti-D Ig 300 microg should be given to nonsensitized D-negative women. (II-3B) 16. Quantitative testing for FMH may be considered following events potentially associated with placental trauma and disruption of the fetomaternal interface (e.g., placental abruption, blunt trauma to the abdomen, cordocentesis, placenta previa with bleeding). There is a substantial risk of FMH over 30 mL with such events, especially with blunt trauma to the abdomen. (III-B) 17. Anti-D 120 microg or 300 microg is recommended in association with testing to quantitate FMH following conditions potentially associated with placental trauma and disruption of the fetomaternal interface (e.g., placental abruption, external cephalic version, blunt trauma to the abdomen, placenta previa with bleeding). If FMH is in excess of the amount covered by the dose given (6 mL or 15 mL fetal RBC), 10 microg additional anti-D should be given for every additional 0.5 mL fetal red blood cells. There is a risk of excess FMH, especially when there has been blunt trauma to the abdomen. (III-B) 18. Verbal or written informed consent must be obtained prior to administration of the blood product Rh immune globulin. (III-C) VALIDATION: These guidelines have been reviewed by the Maternal-Fetal Medicine Committee and the Genetics Committee, with input from the Rh Program of Nova Scotia. Final approval has been given by the Executive and Council of the Society of Obstetricians and Gynaecologists of Canada.

Is Rh immune globulin needed in early first-trimester abortion? A review

The prophylactic use of Rh immune globulin has been a medical success, protecting women who could be at risk from exposure to the Rh(D) antigen. Thus, it is not surprising that Rh(D) immunoprophylaxis has been extended from women with term pregnancies to all women with miscarriages, abortions, and ectopic pregnancies. In this article we review the existing medical literature to assess the risks of fetomaternal hemorrhage and Rh isoimmunization after complications of a first-trimester pregnancy, induced abortion, or ectopic pregnancy. The evidence to support the use of Rh immune globulin in the first trimester is sparse, but there is theoretic evidence of its necessity. Despite weak evidence to support its use, there is little risk.

RhD isoimmunization and current management modalities

OBJECTIVE

To review the literature on current perspectives and treatment of RhD isoimmunization.

DATA SOURCES

A search was conducted on MEDLINE and CINAHL, and supplemental articles/ bulletins were obtained from cited references and the Web site of the American College of Obstetricians and Gynecologists. Recent texts also were reviewed. Key search words: isoimmunization, Rho (d) immune globulin, fetal erythroblastosis, intrauterine blood transfusions, alloimmunization.

STUDY SELECTION

Articles and comprehensive works from indexed journals in the English language relevant to key words and published after 1995 were evaluated. Historically relevant periodicals and texts were also reviewed and selected.

DATA EXTRACTION

Data were extracted and organized under the following headings: testing of the antepartum patient, antepartum treatment of isoimmunization, testing of the postpartum patient, anti-D immune globulin, antepartum anti-D immune globulin prophylaxis, other antepartum and obstetric indications for anti-D immune globulin administration, postpartum anti-D immune globulin prophylaxis, nursing implications, and future possibilities.

DATA SYNTHESIS

RhD isoimmunized pregnancies continue to contribute to worldwide perinatal and neonatal morbidity and mortality. This review describes the basic knowledge necessary to care for these pregnancies and the current management modalities.

CONCLUSIONS

The management options for RhD compromised gestations continue to evolve almost as quickly as technological advances are made. Multiple areas of research in this field have surfaced, and nurses can become valuable members of these research teams. The literature also indicates that with the available knowledge and resources, the current rate of RhD isoimmunization can be further decreased with closer adherence to proposed management guidelines by all health care professionals.

Midwifery management of first trimester bleeding and early pregnancy loss

As many as 25% of women experience bleeding in the first and early second trimester of pregnancy; about half of these will have a miscarriage or, more rarely, ectopic or molar pregnancy loss. This can be a difficult time for women because of the uncertainty of the outcome, lack of preventative measures, and emotional significance of early pregnancy loss. The qualities that characterize midwifery care, including providing complete information, encouraging self-determination, and being sensitive to the emotional state, are particularly important at this time. This article reviews the epidemiology; physiologic process; signs and symptoms of first trimester bleeding; miscarriage and other early pregnancy losses; and methods of clinical, biochemical, and sonographic evaluation. A framework to guide midwifery evaluation and management, based on confirmation of an intrauterine pregnancy followed by the determination of viability, is presented. Surgical, medical, and expectant management of nonviable pregnancy, management of viable pregnancy when bleeding persists, and follow-up care, including screening for psychological sequelae, are discussed. Case studies and specific clinical guidelines for midwifery care, consultation, collaboration, and referral are included. Understanding the emotional significance of first trimester bleeding and loss as a basis for sensitive care throughout the management process is addressed.

Obstetric and gynecologic emergencies

This article reviews the pearls and pitfalls of obstetric and gynecologic emergencies occurring in women presenting to the emergency department. Some pitfalls include failure to screen for ectopic pregnancy, tachycardia as an unreliable indicator of a ruptured ectopic pregnancy, and the use of serum hCG as a testing procedure during pregnancy. Updates include serologic markers of ectopic pregnancy, ultrasonography in the emergency department, methotrexate treatment of ectopic pregnancy, traumatic placental separation, and fetomaternal hemorrhage.